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A TV journalist who has reported extensively on varied matters, from politics, religion, breaking news events to natural disasters. This is an attempt to create a space for larger and deeper issues that don't make the headlines. At least not enough

Family Planning

mMitra, started in Mumbai slums with the support of the civic body, is a free mobile voice call service that gives information on preventive care and simple interventions to reduce maternal and infant deaths. It is given in the language of the user’s choice and sent weekly or twice a week. Launched in 2014, it reaches over 5 lakh women in slums in Mumbai city, up to its far suburbs.

Domestic violence accounts for five in 10 of reported crimes against women in India. Many cases go undocumented, nearly 7 out of 10 women have suffered some form of domestic violence. Domestic violence is linked to posttraumatic stress disorder, gastrointestinal infections, suicide, chronic pain, and increased risk of unintended pregnancy, which, in turn, compromises maternal, infant and child health. The Little Sister’s Project, an initiative that works among victims of domestic violence in Mumbai, has 160 local women to identify and report incidents of gender violence using Android smartphones and an app called EyeWatch.

This documentary was done for the NDTV-Gates Foundation campaign, Every Life Counts. To watch click here

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From April this year, injectable contraceptives will be available in district hospitals across India.

At the recently held International Conference on Family Planning in Bali, top health ministry officials from India said that they were determined to meet their stated target of providing 48 million women with access to contraceptives by the year 2020.

In 2012, at the London Summit on Family Planning, India had pledged to commit almost $2 billion dollars until 2020. As a result, today more women and girls have access to family planning. In 2013 alone, three million additional women and girls in India were equipped with the tools and the information needed to choose a modern contraception method.

To fulfil this goal of 48 million, the government will increase the basket of contraceptive choices offered to women, and promote spacing between births. Apart from injectables, this will include Centchroman, a non-steroidal agent, and POPs or progesterone only pills.

Centchroman, marketed as Saheli, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.

“We are determined that no woman should be left behind and no partner be left behind,” said C.K Mishra, Mission Director, National Health Mission.

Phase 1 results from the fourth National Family Health Survey or NFHS-4 for 2015-16 that covered 13 States and two Union Territories are quite promising with total fertility rates or the average number of children per woman dropping considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.

All states in this phase, except Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade.

However, what remains problematic is the female sterilisation rate, which at 34% is very high. Health officials hope to bring down the numbers by offering more contraceptive choices and improving service delivery.

“All along there has been greater emphasis on terminal methods of family planning and we have not given spacing the attention needed,” said Mishra. “The goal ahead is to focus on adequate spacing”.

Also of concern is the total unmet need for contraception in India, which at 21.3% is the highest in the world. Bringing down the unmet need was a key Millennium Development Goals target that India was unable to meet.

A high unmet need for contraception translates into a high number of unintended pregnancies and has tremendous health implications. India accounts for 19% of the world’s maternal deaths and meeting the need for contraception is critical to saving lives.

“Today more girls and women have access to contraception but we are still 10 million behind in terms of what the figure should be,” said Chris Elias, president of the Global Development Program, Bill & Melinda Gates Foundation, while speaking to a group of journalists on the sidelines of ICFP 2016.

Last November, the Gates Foundation had announced that it would invest an additional US$120 million in FP programs over the next three years to meet the Family Planning 2020 goal of giving 120 million additional women and girls’ access to contraceptives.

“If there is spacing, half of the lives lost would be saved. Women should be able to decide when they should have babies,” believes Elias.

Health ministry officials in India seem to be moving forward in the right direction. However, there is quite some distance to travel before the revised plans are implemented, cautions Poonam Muttreja, Executive Director, Population Foundation of India.

“Apart from issues like inadequate budget allocation, the bigger challenge India faces is wide disparities and inequities in women’s access to healthcare and family planning. Access to health services still depends upon where one lives, how educated one is, and economic and social status”, says Muttreja.

Clearly, the approach will have to go beyond simply making these choices available at various health centres. “It is not just about making the full range of methods available,” says Elias. “Women have to be empowered to make those choices”.

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At the recent International Conference on Family Planning, Indian health ministry officials committed to make available better quality family planning services and expanding contraceptive choices. How much of that will translate into action will depend on the money allocated to health care in this budget.

India has promised to meet the FP2020 goal of providing 48 million additional women and girls in the country with access to modern contraceptives by 2020. Family Planning 2020 is a global partnership that is working with governments, civil society, donors and the private sector to enable 120 million women and girls to decide for themselves, whether, when, and how many children they want.

Reaching 48 million, however, seems like a tall order. India spends just 1.3% of the GDP on health care, which is lower than other countries. China, for instance, spends 2.8% and South Africa 4.1%. Budget 2014-15 saw an 87% drop in funds allocated to family welfare and this was reduced even further by 34% in 2015-16.

The low priority is baffling given that India has among the worst maternal and infant mortality rates in the world. The role family planning plays in achieving broader development goals, including poverty reduction has been well documented.

Population Foundation of India figures show that 46% couples in India do not practise family planning, About 21% of births every year are unplanned, due to lack of access to contraceptives. The cost of unplanned children, according to a PFI study ranges from 2% of state GDP in Tamil Nadu to 14% in Bihar.

In this context, the Health Ministry’s decision to introduce injectable contraceptives in government health centres is a welcome move. The decision was pending for nearly 15 years due to protests from many women’s rights groups. It also plans to promote spacing methods and improve quality of care.

“Meeting the FP2020 goal would need an investment of approximately Rs 13500 crore over seven years (2014 to 2020)”, points out Poonam Muttreja, Executive Director, Population Foundation of India. An additional Rs 11,150 crore would be needed over the next four years, which is Rs 2800 crore per year, adds Muttreja.

Supplying injectables alone will not is be enough say experts. The government needs to rethink its approach towards family planning.

“If you are talking of FP2020 goals, a lot depends on involving men”, says Ashok Dyalchand, Director, Institute of Health Management in Pachod, Maharashtra. “Not enough has been done to involve men and you have a significant proportion of women using contraception without their husbands’ knowledge.”

“The emphasis has been largely on methods for women historically”, adds Muttreja. “The public health system, FP programmes and communication strategies have to change to encourage male engagement”.

For decades India has depended on female sterilization as a means of contraception. It conducts the highest number of tubal ligations – nearly five million in a year. Data from the first phase of the National Family Health Survey (NFHS-4) shows that female sterilisation accounts for 34% of modern contraceptive methods, while less than 1% men go for a vasectomy

One of the main reasons for the low prevalence are the many myths and misconceptions relating to vasectomy says Emily Jane Sullivan from the London School of Hygiene and Tropical Medicines.

“A tubal ligation is a more complicated, costly, and risky procedure than vasectomy”, says Sullivan. “However, in India, more than 1 in 3 women choose to have a tubal ligation while only 1 in 100 men choose to have a vasectomy.”

Countries like Bhutan, Brazil, Nepal, and Rwanda have countered these myths effectively through campaigns that frame men who choose vasectomy as responsible and caring towards their families.

“There is an opportunity for these countries to share their ‘lessons learned’ with other national family planning programs that are looking to thoughtfully, ethically, and effectively promote vasectomy”, says Sullivan.

India needs to look at similar approaches instead of simply adding more to the basket of choices say experts.

“The only addition to the basket is injectables. We do not have male contraceptives. I am in favour of injectables but whether diligence will go into administering it in the government sector is a concern. There is also the question of a strong provider preference towards tubectomies”, cautions Dyalchand.

For decades India has followed a targets and incentives based approach towards family planning. Achieving the FP2020 goal involves a shift away from that. It is not just about technical solutions or contraception, but also about women’s agency, choice, quality of reproductive health services and dignity.

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Activists and experts from around the globe have gathered at Bali, Indonesia, for the 2016 International Conference on Family Planning. It’s an opportunity to take stock of goals that have been met with, and for countries to evaluate how to boost workforces and tweak their approaches toward achieving the new Sustainable Development Goals.

India has a lot to feel proud about. Phase 1 results from the National Family Health Survey-4 for 2015-16 that covered 13 States and two Union Territories show that total fertility rates or the average number of children per woman have dropped considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.

All the states in the first phase, barring Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade. All have rates below 51 deaths per 1,000 live births, although there is considerable variation among the states.

However, there is plenty to be done when it comes to how we approach family planning at the policy level. On this count, India lags behind countries like Sri Lanka and Bangladesh despite being the first country, globally, to have a government-backed family planning program.

India still reports the highest unmet need for contraception worldwide at 21%. In Bihar it is 31% among women between 15-19 years and 33% between 20-24 years. Maternal and neo-natal mortality is five times higher among girls who conceive before they hit the age of 20. They are also more likely to experience spontaneous abortions, infections and anemia.

This is largely because on the ground the emphasis on female sterilization remains high. According to UN data, in India, over 37% of women between 15-49 years use sterilization as a method of contraception. Only 3.1% use a pill and 5.2% rely on condoms.

“The rights perspective on family planning is missing at the policy level and it is high time that this changed”, says Dr Pranita Acharya, Gender, Poverty and HIV/AIDS specialist at the International Centre of Research on Women. “It is the right of couples to decide when and how many children to have. This is only briefly touched upon at the policy level and forgotten on the ground”.

Other contraceptive choices require counseling and careful monitoring – an investment that most states find burdensome. Sterilization, on the other hand, is a one-time, “gunshot” intervention. The result is that many women have been sterilized even before they need it.

Bridging the gap between the two genders in family planning matters is key believes Sushma Shende, Program Director, Maternal and Newborn Health, at SNEHA, a Mumbai-based non profit that works in urban slum communities.

“Considering the socio-economic set-up of the areas in which we work, it is difficult for women to take decisions with respect to FP”, says Shende. “Her husband and mother-in-law play an important role in decisions regarding child bearing and family planning. Moreover, the pressures of bearing and rearing the child is considered to be the responsibility of women so increased awareness amongst the men will make them more supportive and help address misconceptions or fear”.

There is also a near complete lack of awareness when it comes to contraceptive choices among married adolescent girls and newly married couples. Filling this gap is critical given that India accounts for 19% of maternal deaths, worldwide. Educating newly married couples about various contraceptive methods could help prevent many more such deaths.

Challenges top health ministry officials said they are addressing by offering a wider choice of contraceptives, improving service delivery and taking these services to the doorstep of those who need it. Speaking at the India Caucus held on the eve of the 2016 International Conference on Family Planning, C.K Mishra, Mission Director, National Rural Health Mission said that the goal ahead was “to ensure no woman should be left behind and no partner should be left behind”.

Admitting that the focus on female sterilisation was troubling, Mishra said there was now greater emphasis on expanding the basket of contraceptive choices to include injectables, Centchroman, a non-steroidal agent and POPs or progesterone only pills. Centchroman, marketed as Saheli, is a potent non-steroidal non-hormonal birth control method, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.

Attractive packaging for contraceptives, a sharper FP communication campaign and mobilising local health workers is also being looked at to add momentum to India’s family planning program.

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Mention Genderussa, and most people imagine it to be a feminine hygiene product. In fact it is the world’s first non-hormonal, oral male contraceptive drug, currently in the third phase of clinical trials in Indonesia. If all goes well, it will hit the markets here early 2013.

Genderussa capsules

The question everyone is asking however is, will men have it? Indonesian health experts are hoping they will. At nearly 237 million,Indonesia is the fourth most populous country in the world. The government here has taken a huge initiative in curbing population growth, but its progress has been hampered by the lack of male participation, with less than 2% of men chipping in. Genderussa, experts here are hoping will change that age-old mindset. ‘’Family planning is not just for women. It’s a decision made by the couple, ‘’ says Dr Sugiri Syarief of the national Demographic and Family planning agency, BkkbN.

Derived from the native Justicia Genderussa plant which grows in Papua, Indonesia, research into the pill started in 1987, after some experts found that men on these islands traditionally used the genderussa leaves as a contraceptive. Local laws do not allow the men to get married unless they pay a huge dowry. They can, however live in with their partners, as long as they do not have children.

Justicia genderussa

“Our tests showed the leaves had properties that disturb the enzyme system of the sperm,’’ says Prof Bambang Prajogo, Senior Researcher at the Faculty of Pharmacy, Airlagga University in Surabaya which is conducting the trials. Genderussa, however is a toxic plant, and the alkaloids are removed with an acidic solution. Traditionally the people would boil the whole plant to eliminate the toxic compounds. ‘’We have done tests to ensure there is no pesticide residue, ash content, microbes and radioactive impurities in the leaves,’’ claims Prajogo. The findings have been published in an Indonesian journal, but not as yet internationally.

‘’Genderussa guarantees safety, quality and efficacy as per WHO requirements on contraceptive drugs,’’ says Dr Dyan Pramesti, who is leading the clinical trials. There is a common side effect, namely abdominal discomfort. One subject we spoke to however said he would recommend the pill to his friends.

Dr Dyan Premasti

Islam allows non permanent methods of family planning. So genderussa fits right in. It’s taken like any birth control pill, one dose a day. If it works, and passes safety standards in other countries, it could well revolutionize the way the world looks at family planning. Hormonal contraceptives are endangering the lives of many women. Genderussa, which is non-hormonal, could prevent that. Last, and most important, it’s a fundamental move towards gender equality.

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One of the hardest things for journalists is to pitch a story that does not fit into the ‘’breaking news’’ slot. And this is not just the case in India. When it comes to health or any other development-related issue for that matter, fighting for news space is quite hard.

Take maternal mortality or poor health infrastructure in villages for instance. Huge concerns in India. Reports on these tend to get buried unless there is a shocking peg, like a pregnant woman dying on the streets because no hospital would admit her. And if this was to clash with, say the Indian cricket team’s return after some huge win, well forget about it.

How does one get around this? Here in Indonesia, theBkkbN, the government’s National Population and Family Planning Board, that has played a seminal role in curbing the country’s population growth, has a partnership with the local media. This, they say, has helped in two ways. One, the media has helped spread information about its various services to the provinces. Two, it gets feedback on what’s going wrong. I can see a few eyebrows being raised here. The media after all is meant to take on the government, question it, although one could perhaps do with more of that, at least in India.

Across many provinces, the BkkbN has set up the Family Planning Journalists Association, made up of local reporters who are given training in population and FP issues. Orientations help familiarize them with the various contraceptive methods and services provided by the state. The groups change every 4 years, and what’s important to note is that they are not on the BkkbN’s payroll.

‘’The media have played a big role in the FP program’s success,’’ says Siti Fatonah, Head, BkkbN West Java. West Java is one of the biggest provinces, its population contributing to 20% of Indonesia’s total. ‘’Putting the right kind of image forward was difficult for us. The media has helped. We get to know about field workers demanding payment for free services,” adds Fatonah.

But how free and frank is this partnership really, one can’t help but wonder.

‘’They do not interfere. They never stop us from writing negative stories. We often report on things that are going wrong,’’ says Sulhan Syafe, who heads the West Java FPJA. What attracted him towards taking up the position? ‘’After Suharto stepped down and democracy came to Indonesia, the media could write what it wanted. But no one cared about FP related issues. I do this because I know journalists lack information and perspective about our FP program. I have seen how farmers with 6-7 children struggle to feed their families and this issue is critical for Indonesia,’’ says Syalfe.

The government support, however, does not ensure that FP issues always get played up. ‘’I have to fight, beg and plead with my editor to carry stories. They are always willing to give space to politics and to stories about Lady Gaga’s concert being called off,’’ says Elly Burhaini Faizal, Correspondent with The Jakarta Post.

BkkbN credits its FP program’s success, to a large extent, to its partnership with the media. Something it needs to build on given the tremendous challenges that still lie ahead. Indonesia is the fourth most populous country in the world, and there is poor health infrastructure in the remote provinces. One suggestion is that the government should perhaps widen its media partnership to include senior editors!

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It has the world’s largest Muslim population, yet Indonesia is widely regarded as the poster child of successful family planning. A remarkable achievement, given that as recent as in the early 70’s, the average family size here was 5.6 births per woman. Today that stands at 2.3 and all this in a span of just over four decades. Indonesia’s approach has lessons for many, including India which at 2.73 births per woman is far from the Millennium Development Goal of 2.1.

The government here has done this through partnership with various stakeholders – community leaders, media, private health sector and more importantly religious leaders. Getting leaders from groups like the Muhammediya has been critical to the program’s success. One of Indonesia’s oldest Faith Based Organizations, the Muhammadiya was formed in November 1912 in Yogyakarta. It has leaders in all thirty three provinces in the country and supports key government initiatives in health and education.

“But doesn’t Islam discourage family planning”, I ask Dr Atikah M Zaki, Health and Social Coordinator of the Aisyiyah, the women’s wing of the Muhammediya group. “Islam is not against temporary methods,” Dr Zaki points out. “We encourage pills, IUD, injections and spacing. It is permanent methods like abortions and sterilizations that are not allowed.”

The group even counsels couples who are divided over FP. “When the wife wants to delay babies and the husband is opposed to it, our local leaders intervene and convince him,” says Dr Fifi Maghfirah. In fact the Muhammediya was the first Islamic organization in the world to promote FP. “In most Muslim countries there is no difference of opinion on temporary methods of contraception,” says Farahanaz Zahidi Moazzam, a freelance journalist and activist from Pakistan. “But the difference between Indonesia and other Muslim countries is that it is discussed openly here. What is remarkable is that the organization is using religion to promote FP,” Moazzam adds.

It is a tactic that could work in India where family planning remains a sensitive topic. Bringing community leaders on board could help overcome reservations that decades of the government’s ‘’Hum Do Hamare Do’’ (We are two, and we have two) campaigns have not.